Lower Oesophagus Lined with Intestinal and Gastric Epithelia

Abstract

The patient first had symptoms at the age of 14 years when he began to suffer from heartburn. This came on when he was lying down and was relieved when he sat up. Indigestion was also caused by eating pickles. The symptoms recurred intermittently and gradually grew worse. At the age of 24 years, while serving as a seaman in Malta, he began to experien-e burning pain in the epigastrium and he was admitted to hospital for investigation. A barium meal was reported as showing a normal stomach and duodenum, and passage of the barium through the remainder of the bowel was normal. He was treated by bed rest and alkalis. He felt better for about four years, but then in 1960 at the age of 30 years the symptoms recurred. Once again he began to suffer from heartburn which was aggravated by lying down and was usually experienced at night. In addition he complained of intermittent dysphagia of eight months' duration. At the time of admission to hospital he was able to swallow only fluids and semi-solids and as a result of this he had lost about 2 stones (12-7 kg.) in weight.On examination he was a fit-looking man weighing 10 st. 9 lb. (67 5 kg.). A barium meal showed a stricture with a wide lumen just below the aortic arch (Fig. 1). Below this the oesophagus was wide and passed straight down into the stomach. In the erect position, after drinking approximately 200 ml. of barium meal, the stomach contents rose 2 in. (5 cm.) above the diaphragm on inspiration. When he lay down, the stomach contents ran straight up the oesophagus and only when they passed above the stricture did he experience heartburn. At oesophagoscopy it was noted that the oesophagus above the stricture was a little dilated and hyperaemic but was otherwise normal in appearance. The stricture itself (at 30 cm.) was very red and bled easily. The oesophagoscope passed through it with ease. Below the stricture the mucosa was redder than above. At 37 cm. the end of the oesophagoscope reached the cardia and passed into the stomach. Biopsies were taken at 24, 27, 30, 33, 37, and 38 cm.Operation was carried out on 10 January 1961. The left lower chest was opened and the oesophagus looked entirely normal but for the fact that the cardia 66 appeared to be at 37 cm., 3 cm. above the right crus. This was judged by the change from the rather rough longitudinal muscle to a smooth stomach wall, and by the attachment of the peritoneum. The limbs of the right crus were widely divaricated. An incision was made in the diaphragm to allow inspection of the stomach. This was normal in size, shape, and position apart from the small hiatus hernia. On palpating the oesophagus in the region of the aortic arch there was a soft, mobile mucosal thickening. A repair of the hiatus hernia was carried out, the limb of the right crus being sutured in front of the oesophagus. There was immediate relief of the dysphagia and heartburn after the operation. A postoperative barium meal showed no hold-up, and it was not possible to provoke reflux by the usual manceuvres.After operation he gained 1 ...

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